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{ APPLICATIONJOR PERMIT SRN JOAQCiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I/v� Telephone (209) 466-6781 DATE ISSUEO.2Zn&,—� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump k and the Rules and Regulations of t e San Joaquin Local Health District. Joh Address y 44 Subdivision Name Owner's Name _ .ih Address d —e Phone 47 Contractor's Name ) license No. 9!C� » Phone 10/02 T TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION �PJMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �c� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. EINE U FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing ❑ Public 0 Other ❑Delta Type of Casing ❑j Irrigation Approx. ❑Eastern Specifications ❑ Cathodic Protection Depth Depth of Grout Seal ❑Geophysical ❑Other Type of Grout Surface Seal Installed by Repair Work'Done ❑ Type of Pump H.P. State Work Done .h t/1 " Well Destruc 'on , Well, Diameter _�QSealing Material (top 50') _ vvs Depth 2 423��_ Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units' Number of bedrooms Lot size Character of soil to a�depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal t SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS ❑ Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line EDISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall, not employ any person in such manner as to become subject to workman compensation laws of California." I Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I`shall employ persons subject to workman's compensation laws of California." The applicant must call 'hfor all required inspections. Complete drawing on reverse side. Signed )F 5. fffj[.4/ Title: Date: - i OR 294TY USE ONLY r ( Application Accepted by Area O Stk 466-678 R Pml,4 Additional Comments: G ❑ Lodi 369-3621 Pit or Grout Inspection by Date ❑ Manteca 823-7104 Final Inspection;by Date y^r, ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.0, Box 2009, Stk., CA 95201 ' FEE BASEiAMOUNT DUE AMOUNT REMITTED RECEIVED BY gDATE PERMIT NO. INFO I s--� 0 �� I EH 13-24 REV. 10/82 10/82 500 14-26 Volk ` ca_!5r� ��lll///��-----��////1111 -